2015 Camp Honey Shine Application Form ** $40.00 Registration Fee Required** June 15 - July 24, 2015 Located at: Carrollton School – Duchesen Campus 3747 Main Highway, Coconut Grove, FL 33133 Instructions: To Parent or Legal Guardian, any information given in this application will remain strictly confidential. Please fill out this application completely using a permanent ink pen only. Please print clearly except when you are asked for your signature. CAMPER INFORMATION Social Security Number ______/ _/ _ Date of Birth ______/______/______ Age Camper’s Name: First _______________________ Middle Initial ___ Last ____________________________ Address _________________________________________________________________________________ (Street) (Apt.#) (City) (State) (Zip) Home Phone _________________________________ Alternative Phone ____________________________ EMAIL: _______________________________________ 2ND EMAIL_________________________________ Ethnicity: [] African-American [] Asian [] Caucasian [] Hispanic [] Native American Descent: ____________________________ (Example: Haitian, Jamaican, Cuban, Peruvian, etc.) Current Grade __________________ School Currently Attending ____________________________ Grade in school NEXT FALL ________ at School ________________________________________________ Clothing Size: XS S M Children’s L XL Junior’s XXL | Shoe Size: Adult | | Bathing Suite Size: Child Adult | Children’s Junior’s Adult HOUSEHOLD INFORMATION Mother’s Name ___________________________________________________________________________ Mother’s Telephone (H) _____________________ (W) ______________________ (C) __________________ Father’s Name ___________________________________________________________________________ Father’s Telephone (H) ______________________ (W) ____________________ (C) ___________________ Legal Guardian (if other than parent) __________________________________________________________ Guardian’s Telephone (H) _____________________ (W) _____________________ (C) _________________ Name of Adult that Camper lives with (if other than parent) _________________________________________ APPLICATION – PART II Camper’s Full Name: ______________________________ SSN: _________________________ EMERGENCY/MEDICAL INFORMATION In case of emergency, please notify: __________________________________________________________ Address: ________________________________________________________________________________ Phone: _________________ ____________________ _______________________ Home Work Alternative Health Plan/Insurance Co: __________________________________________________________________ Policy Number ___________________________________________________________________________ Regular Physician: ________________________________ Physician’s Phone ____________________ Hospital Preferred: ________________________________________________________________________ Check here if currently enrolled in the Florida Medicaid Program Please indicate any conditions that would affect your child’s participation in activities, including medical conditions and/or allergies: ___________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Note: Please contact the Honey Shine, Inc. Mentoring Program office with any changes of the above information. It is imperative that this information is current at all times to best serve you and your child in an emergency. If my child is injured while participating in any activities and I cannot be reached, I give the Honey Shine, Inc. Mentoring Program my permission to treat my child promptly at an emergency medical facility. _________________________________________ Parent/Guardian Signature _____________________________ Date DIETARY CONCERNS Please list any food allergies: Please list any dietary concerns: PUBLICITY RELEASE Many parents enjoy seeing their children’s pictures in the newspaper and on television; however, some parents do not want their children identified for various reasons. If you do not want your child photographed, Honey Shine, Inc. will make an extra effort to see that your child is not available to the news media. Realistically, all situations cannot be controlled, and Honey Shine, Inc. cannot guarantee that a child will not be identified in the news media reports, etc. NO I DO NOT WANT my child to be photographed or interviewed by the news media. YES I DO WANT my child to be photographed or interviewed by the news media. 100 S. Biscayne Blvd. 3rd Floor, Miami, FL 33131 0ffice: 305-854-2444 [email protected] www.honeyshine.org Page 2 of 6 APPLICATION - PART III Camper’s Full Name: ______________________________ SSN: _________________________ RELEASE AND WAIVER PLEASE READ THIS CAREFULLY. By signing this legal document, you are giving up any legal rights you may have to sue Honey Shine, Inc., Mourning Family Foundation, and Carrollton School of the Sacred Heart and all other Mourning Family Foundation organizers and sponsors in court for money damages. I desire to participate in or attend the games, activities and events related to Honey Shine, Inc. Mentoring Program Summer Camp (Camp Honey Shine), which is sponsored, produced and/or organized by Mourning Family Foundation including but not limited to Carrollton School of the Sacred Heart, Mourning Family Foundation, Honey Shine, Inc., and all other organizers and sponsors. In exchange for the ability to participate in or attend the camp, I hereby irrevocably and unconditionally agree for myself and my heirs, estate, insurers, successors and assigns, as follows: 1. ASSUMPTION OF RISK. I understand that participation in or attendance at the Camp may involve inherent risks and dangers of accidents, property loss or damage, serious personal and bodily injury, death, and severe, social, and economic losses. These may result in not only from my own actions, inactions, or negligence, but the actions, inactions, or negligence of others, the rules of play, or the condition of the facilities, equipment, or vehicles. Further, there may be other risks not known to me or reasonably foreseeable at this time. I understand and I have considered and evaluated the nature, scope, and extent of the risks involved, and I voluntarily and freely choose to assume these risks. I warrant that I suffer from no minor or serious injury, illness or disability that would make me especially susceptible to injury or disability and that I am physically able to fully participate in the camp. 2. RELEASE FROM LIABILITY. I fully and forever release, and discharge the Camp Counselors, their subsidiaries, directors, offices, employees, agents, insurers, sponsors, advertisers, owners, or operators, of the Camp, facilities, equipment, and vehicles, and all others involved in the camp (the “Released Parties”) from any and all injuries (including death), losses, damages, claims (including negligence claims), demands, lawsuits, expenses, and any other liability of any kind, of or to me, my property, or any other person, directly or indirectly arising out of or in connection with my participation in or attendance at the Camp, including transportation related to the Camp, even if it is due to the negligence or other fault of the Released Parties. I waive my insurers’ right to make a claim against the Released Parties based on payments by insurers to me or on my behalf for any reason. This means my insurers have no right of subrogation. 3. NO INSURANCE; MEDICAL EXPENSES. I understand that Honey Shine, Inc and Mourning Family Foundation does not provide me with any insurance, either life, medical or liability, for any illness, accident, injury, loss, or damage that may arise in connection, with my participation in or attendance at the Camp. If I want insurance of any kind, I must obtain my own. I will pay my own medical emergency expenses and all subsequent medical expenses in the Camp of any illness, accident, or injury in connection with the Camp. 4. AUTHORIZATION TO USE IMAGE AND OTHER INFORMATION. Honey Shine, Inc and Mourning Family Foundation may be photographing and/or filming the Camp for advertising, promotional, or other commercial purposes, including for television, cable and/or Internet broadcast. I hereby consent and agree that photographs, film, and video may be taken of me and that Honey Shine, Inc and Mourning Family Foundation their affiliates, and assigns may use, without compensation, my photograph, video or film portrayal, image, likeness and voice, as well as any information, in any media for any lawful purpose. 5. VALIDITY. If any portion of this Release and Waiver is held to be invalid or unenforceable, all other provisions shall nevertheless continue to be valid and enforceable. This Release and Waiver supersedes any oral or written statements made by or to me. I HAVE READ THIS RELEASE AND WAIVER CAREFUYLLY, FULLY UNDERSTAND ITS CONTENT, AND VOLUNTARILY AGREE TO ITS TERMS. _______________________________ PARENT/GUARDIAN (PRINT) ______________________________ PARENT/GUARDIAN (SIGNATURE) ________________ DATE 100 S. Biscayne Blvd. 3rd Floor, Miami, FL 33131 0ffice: 305-854-2444 [email protected] www.honeyshine.org Page 3 of 6 APPLICATION - PART IV Camper’s Full Name: ______________________________ SSN: _________________________ COUNSELING SERVICES WAIVER The Honey Shine, Inc. encourages the balance of mind, body and soul in girls and women by providing nurturing experiences that enlighten their paths and empower their future. Throughout the program year, we will have the opportunity for counseling sessions in conjunction with Barry University Family Enrichment Center (Barry). This release will authorize Barry and Honey Shine to obtain and release information to and from the girls (Honey Bugs) attending group and individual counseling sessions. Barry is able to provide counseling services to the girls and their families (if you are interested please let Honey Shine know). Full Name of Participant (Honey Bug) (PLEASE PRINT) Date of Birth Full Name of Participants Parent/Guardian (PLEASE PRINT) Street Address Home Phone Number City State Cell Phone Number Zip Work Phone Number Information to be released include a treatment/discharge summary, treatment progress report, verbal exchange of information, and any videotape(s) of sessions. This information has been disclosed to you from records whose confidentiality is protected by Florida Law (394.459, 397.053, 381.609, 455, and 90). I also understand that my records are protected under the federal regulations governing confidentiality (42 CFR Part 2), and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing, at any time except to the extent that information has already been released in compliance with this authorization. This consent is valid for 365 days from the date signed. I hereby authorize Honey Shine, Inc. and the Barry Enrichment Center to provide treatment and/or counseling as deemed necessary by the Center Staff. I understand that Honey Shine and the Barry Enrichment Center will provide reports to the Court and/or the Department of Children and Families (if applicable) as required by law and that I will be provided a courtesy. SIGNATURE OF PARENT/GUARDIAN DATE SIGNATURE OF WITNESS (HONEY SHINE STAFF) DATE 100 S. Biscayne Blvd. 3rd Floor, Miami, FL 33131 0ffice: 305-854-2444 [email protected] www.honeyshine.org Page 4 of 6 APPLICATION - PART V Camper’s Full Name: ______________________________ SSN: _________________________ FIELDTRIP PERMISSION FORM The Honey Shine,Inc. Mentoring Program (Honey Shine) encourages the balance of mind, body and soul in girls and women by providing nurturing experiences that enlighten their paths and empower their future. Honey Shine has arranged several fieldtrips during Camp Honey Shine that will allow the girls to experience new places, learn about different topics, as well as increase their service to the South Florida community. Honey Shine, Inc. will provide transportation for each fieldtrip from the Carrollton School of the Sacred Heart to the location of the activity. Honey Shine will also cover any admission cost for fieldtrips. Participants (Honey Bugs) are to dress appropriately for every field trip during Camp Honey Shine – Honey Shine T-shirt Shorts or Jeans Closed toe shoes By signing this form, I relieve Honey Shine, Inc. Mentoring Program from any liability that might transpire during these activities including transporting participants to and from the event and during the activity. Should you have any questions or concerns, please contact Honey Shine at 305-854-2444 or by email at [email protected]. Thank you for your cooperation! Sincerely, Honey Shine, Inc. (Print Names in this section) I, , give permission for, to attend fieldtrips planned by the Honey Shine, Inc. Mentoring Program during Camp Honey Shine 2015. SIGNATURE OF PARENT/GUARDIAN DATE 100 S. Biscayne Blvd. 3rd Floor, Miami, FL 33131 0ffice: 305-854-2444 [email protected] www.honeyshine.org Page 5 of 6 APPLICATION - PART VI Camper’s Full Name: ______________________________ SSN: _________________________ CAMP HONEY SHINE PROGRAM Camp Sessions: (Please check all that apply): [] All Sessions: June 15 – July 24, 2015 [] Session A: June 15 – June 19 [] Session B: June 22 – June 26 [] Session C: June 29 – July 2 (Note: July 3, 2015 is a Camp Honey Shine Holiday) [] Session D: July 6 – July 10 [] Session C: July 13 – July 17 [] Session C: July 20 – July 24 [] Robotics Camp *Tulips and Roses: (limited space, participation TBD) PERMISSION FOR ENROLLMENT I give my child permission to participate in “Camp Honey Shine” activities. I have read and am voluntarily signing this authorization. I have read all forms and grant permission for my child ________________________________________ to participate in all activities provided by the Honey Shine, Inc. Mentoring Program. _________________________________________ PARENT/GUARDIAN SIGNATURE _____________________________ DATE CAMPER COMMITMENT I want to become a Honey Bug at Camp Honey Shine. I agree to abide by all camp rules. I will do my best to make this a good experience for myself and for my fellow campers. I understand that failure to live up to this promise could result in my dismissal from camp. CAMPER’S SIGNATURE DATE ** The $40.00 Registration Fee must be turned in with the application. If paying my check or money order make it payable to Honey Shine, Inc. If paying by credit card or debit card visit our website www.honeyshine.org and enter it under donation ** 100 S. Biscayne Blvd. 3rd Floor, Miami, FL 33131 0ffice: 305-854-2444 [email protected] www.honeyshine.org Page 6 of 6
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